Letters to the Editor: Prince Fentanyl Overdose, High-Dose Opioids, Mystery Care
Prince Died of Fentanyl Overdose
Practical Pain Management has had an overwhelming response to our report on the accidental overdose death of legendary musician Prince.1 Many of the comments are from chronic pain patients. The following is a selection of their comments.
I can definitely understand how Prince died from using fentanyl. I used the patches for years. I have lupus, rheumatoid arthritis, and fibromyalgia. Also, I had a cervical spine fusion. The patches are great, especially if you have multiple chronic pain problems. I was pain free for a long time, and then my body became immune to them. I was so tempted to double the dose, but after consulting with my pain management doctor, and reading up on fentanyl, I realized it could kill you instantly. I had to change pain medications; oxycodone, and other pain medicines, never did work as well as the patches did.
Glad to see comments about people with chronic pain needing their prescribed opiates. People who live with daily pain need whichever opiate their well-educated doctor prescribes for them. If medications are not taken as prescribed, or medications are purchased by other avenues than prescription, it is wrong.People who suffer with conditions that require the use of opioids should not be looked down upon. Nor should their doctors’ hands be tied!
Please understand that much of the fentanyl that is being seen in these overdoses is not prescription grade, and doesn’t come from a patch or lollipop. It is “backyard grade” fentanyl that is being produced in illicit basement labs and sold as heroin or fentanyl. On a toxicological report, the 2 can’t be differentiated. Prince may have had a prescription for fentanyl due to previous [pain] issues, or he may have gotten it from the streets. More people are dying of fentanyl in my community than heroin, and it’s not from the patch.
I am the physician in charge of Kaiser’s pain management department in San Diego—we have over 650,000 members in the area.
Our administration has asked our department to take over all patients who are taking more than 500 mg per day of morphine equivalents for their chronic pain, and their opiate refills.
Of course, most of these patients have been through our department at some time. I feel that having our department see these patients, and make opioid dosing recommendations and give advice (mostly about weaning), is support enough for the primary care physicians to refill these patient’s opiates according to any treatment plan.
The medical group wants us to assume all refills. Is it outside the standard of care for a primary care physician to refill high-dose opioid prescriptions under the guidance of a pain management doctor?
Michael Jaffe, DO
Physician In Charge
Integrated Pain Management
Physical Medicine and Rehabilitation
Dear Dr. Jaffe,
Your question and issue is most timely and critical. The timing of your situation, and many others, appears to be related to the new and widely-published Center for Disease Control and Prevention (CDC) guidelines on opioid prescribing.2
There are 2 major problems in pain management today:
1. All the new guidelines want a pain specialist to attend every patient who needs a daily morphine equivalent dosage of about 100 mg per day. The problem is simply that we don’t have enough pain specialists to go around.
2. We have many chronic pain patients who were started on high-dose opioids years ago, before we had alternatives such as neuropathic agents, low-dose naltrexone, ketamine, and neurohormones, etc. Many of these “legacy” patients are doing very well on their high-dose regimen and don’t wish to change. In addition, no party in pain management has found a consistent, reliable, and cost-effective way to reduce opioid dosages.
Let me say that having a primary care physician refill high-dose opioid prescriptions under a specialist’s guidance is not only a good “standard of care,” it is now, essentially, mandatory practice. We have no other option given the high number of legacy patients, and the growing shortage of pain specialists.
A couple of years ago, I personally became so inundated with legacy patients that I identified 3 primary care physicians in my local community who were willing to donate some of their practice time to see a limited number of high-dose opioid patients. We meet monthly for training and consultation. We have adopted standard forms and prescriptions. A great deal of training time has been dedicated to regulatory compliance and to prescription safety (risk vs benefits, drug screening, functional assessment).
Recently a colleague with a doctor of pharmacy degree (PharmD) has received his Drug Enforcement Agency (DEA) license, and is now part of our network and starting to see a few of the legacy, high-dose cases.
It is incumbent on all of us to stop the hysteria surrounding the opioid issue and educate all parties that we are short on manpower, and that we have no magic answers to reducing opioid dosage in patients who were prescribed, in good faith, high-dose opioids a few years ago. In contrast to past years, we now have good alternatives to opioids, and today rarely have to go above 500 mg of daily morphine equivalents to help our patients.